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Honored Contributor
Posts: 14,294
Registered: ‎11-03-2018

Re: Insurance Won't Pay for Preventive Colonoscopy!


@Lipstickdiva wrote:

@Bri369 wrote:

@Lipstickdiva 

 

When are you having this done?

 


@Bri369, May 3.  Now I sort of wish I would have just had it done next week when they initially wanted me to come in.  

 

I really wanted to wait until after we come back from vacation in the event something is wrong.  But I make myself such a wreck over this type of thing that I should have just gone and gotten it over with.  I'm so ridiculous about this stuff. Woman Sad   


I'm sure nothing will be wrong.

 

It's very true - the prep is the worst part of it.  Even if they do find a polyp, it's better to find it sooner rather than later.  You're not in any pain when you wake up. 

 

I get what you're saying about getting it over with though.  Enjoy your vacation!

 

Honored Contributor
Posts: 30,916
Registered: ‎05-10-2010

Re: Insurance Won't Pay for Preventive Colonoscopy!

[ Edited ]

This went off the rails...LOL   I think OP posted just to advise others about this and to encourage people to check coverage with their insurance company.  She was not asking for advice because she understands that it is contractually not covered in her contract.  There's absolutely now way around something that is contractually not covered....otherwise... what would be the point of a contract?  Don't forget, the insurer's contract is with the employer, not the employee.  Every health insurer, public or private, denies coverage for some services or procedures.  It's not a matter of anyone being "wrong" if it's documented and in this case, confirmed by OP's physician's office.  And while we are at it, the doctor's office was not required to tell the OP that screening colonoscopies are not covered unless they were doing the procedure.  As a courtesy to their patients, many doctor's offices do veryify coverage for their patients but many do not.  

Honored Contributor
Posts: 18,604
Registered: ‎10-25-2010

Re: Insurance Won't Pay for Preventive Colonoscopy!


@NicksmomESQ wrote:

@Lipstickdiva  Something doesn’t sound right.I would challenge that decision. The ACA made it so all insurance plans had to cover preventative testing at 100%. I’ve learned from previous experience that when you go up the ladder & challenge these things you have a good chance of prevailing.It sounds to me like the insurance company is getting away with it because they’ve gone unchallenged.


Many employers are self ensured.  That means you do not have insurance with an insurance company.  The insurance company only processes the claims for the employer.

 

These self insured policies are not subject to any laws pertaining to health insurance.  Self insured companies are really common, especially with large companies.  There is no reason to appeal these types claims.  Only the employer can pay a claim by exception.

 

Most policies that I have seen will cover a preventative colonoscopy starting at age 50 and every 5 years thereafter.  Some other policies will only cover a sigmoidoscopy on a preventative basis...the OP should ask to see if hers does.

 

Anytime a colonoscopy is ordered because of belly pain, digestive issues, bleeding,etc.  it is a diagnostic procedure and be covered according to the terms of your contract.

 

Honored Contributor
Posts: 10,168
Registered: ‎03-14-2010

Re: Insurance Won't Pay for Preventive Colonoscopy!

What happened to all the wellness coverage insurance companies were touting a few years ago? I hope whatever new insurance system to replace ACA is passed will look at all the pitfalls that exist right now and fix them! Wellness and preexisting should be integral.
Honored Contributor
Posts: 18,604
Registered: ‎10-25-2010

Re: Insurance Won't Pay for Preventive Colonoscopy!


@Bri369 wrote:

@Lipstickdiva wrote:

@Bri369 wrote:

I'm really surprised.

 

Will the doctor's office give you a break on the price because you're a self-pay? 

 

Is the Cologuard an option for you?

 


@Bri369, Yes there is a cost break as a self-pay.  

 

I don't want to do Cologuard because it is reportedly highly inaccurate, often giving both false positives and false negatives.  But even if I was okay with it, you have to get a prescription from the doctor for it and my doctor will not do that because she doesn't consider it an accurate test.  

 

I keep telling myself that if they find nothing, fingers crossed, I don't have to go back for 10 years so if I divide the cost by that 10 years, it's really not bad.  LOL      


That's really awful. 

 

The thing that worries me about hospital procedures that aren't covered by insurance is what if something happens and there are complications?Is that covered by your insurance or are you a self-pay for everything that followed the original procedure?

 

 


In most cases, serious complications that come about from an uncovered service are covered by insurance.  I have seen issues with non covered cosmetic procedures...like excessive bleeding and those services were covered.

Honored Contributor
Posts: 10,168
Registered: ‎03-14-2010

Re: Insurance Won't Pay for Preventive Colonoscopy!

You must ask the dr office to verify what is covered...they do t do it automatically.
Honored Contributor
Posts: 10,168
Registered: ‎03-14-2010

Re: Insurance Won't Pay for Preventive Colonoscopy!

It is rare any procedure is covered 100% by every insurance company...they always find a way to put loopholes in the fine print. I hate dealing with insurance companies! Important to remember the best and sometimes only advocate you have is yourself....don’t expect anyone at the drs office to be looking out for your best interest....only in a perfect world, they would.
Honored Contributor
Posts: 10,168
Registered: ‎03-14-2010

Re: Insurance Won't Pay for Preventive Colonoscopy!

I would find out exactly how much you will be paying before you drink the first bit of that yucky prep stuff.
Esteemed Contributor
Posts: 6,504
Registered: ‎05-22-2014

Re: Insurance Won't Pay for Preventive Colonoscopy!

I might be in the minority here, but my preps for colonoscopies has not the the ultimate horror show.  You drink and go to the bathroom.  Not pleasant, but not the worst thing.  

 

I am so sorry you are having to endure problems in payment from your insurance company.  I look forward to the day that insurance companies, which exist just to make a profit, are not in charge of health care.  Your experience is shameful.  Best of luck to you.  The whole process will be much smoother than you think.  Nowadays the anesthesia takes hold so fast, when you open your eyes it will all be over.  Really!

Pam

Respected Contributor
Posts: 4,640
Registered: ‎03-09-2010

Re: Insurance Won't Pay for Preventive Colonoscopy!

I always though colonoscopies were considered a part of the "well woman/man" stuff that you're supposed to have at certain ages.  I had my 1st one at age 50 (in 2000), the recommended age for folks to start getting them.